ABSTRACT
Background Vulvodynia, characterized by burning sensation, pain, and pruritus, is often treated with antidepressants. Recent studies indicate that acupuncture may be an effective modality.Objective To evaluate the short-term effect of acupuncture on vulvodynia.Design, Setting, and Patients A convenience sample of 13 patients in a private clinic setting.Intervention Acupuncture at 3 main points for all patients: BL 22, SP 6, and LV 5, alternatively on the left and right meridians, in 4 weekly
treatments.Main Outcome Measure Pain measured on a 10-point visual analog scale (VAS) before and at the end of treatment, and 3 months later (at 4 months).Results Significant differences (at P<.001) were observed between pretreatment, and 1 and 4 months later, from a VAS mean of 8.69 to 4.38 and 2.31, respectively.Conclusions Acupuncture appears to be a possible alternative to antidepressant treatment for vulvodynia. A longer surveillance period is
needed to verify our results.KEY WORDSVulvodynia, Acupuncture, Vulvar Dysesthesia, Vulvar Pain, Visual Analog Scale (VAS)

INTRODUCTIONThe prevalence of vulvodynia, or generalized vulvar dysesthesia, is largely unknown in the general population.1 It was described by Tovell and Young in 19782 as an undetermined disorder in 26 patients (2.6%) in a series of 877 consecutive cases. The diagnosis was founded on an eliminatory basis for skin lesions. Patients were distressed by a burning sensation, pain, and pruritus, and the term “pudendagra” was used. The concept of vulvodynia or chronic vulvar discomfort was accepted in 1984.3 McKay4 differentiated pruritic symptoms, as associated with skin changes, thus confirming vulvodynia as an exclusion syndrome associated to a disorder of unmyelinated C fibers. Tricyclic antidepressants amitriptyline and desipramine are typically first-line therapies5 but recently, new avenues have been evoked in 2 pilot studies on acupuncture for the simplicity of use and rapid clinical response.6,7

Danielsson et al,6 using a visual analog scale (VAS), noted significant changes (P=.01) for negative quality of life at 3 months following treatment: from a score of 7.2 to 3.2 in a series of 14 women. Pain at coitus was included in the sample of vulvar vestibulitis. Powell and Wojnarowska7 reported in 1999 a clinical response in 12 patients: 2 of the cases were stratified as cured, 3 cases with partial improvement, and 4 slightly improved.

In order to verify the possible action of acupuncture on vulvodynia, we reviewed 13 cases of generalized vulvar dysesthesia, without any coital pain or sexual interference.

METHODSThirteen patients with general vulvar dysesthesia filled out the Stanford pain visual questionnaire (VAS, 1-10) in an office setting with us.8 Verbal consent was obtained from all patients. No double-blind intervention or controls were used; this pilot study was strictly an evaluation of acupuncture effectiveness on vulvodynia patients. Patients were seen by their physician before and after acupuncture; they were informed about the technique and mechanisms on all spheres of their body, nervous system, Qi/xue, body, and mind. Our inquiry included patient age, duration of disease, and pain score before acupuncture, at 1 month, at the end of 4 weekly treatments, and at 4 months, or 3 months after the end of the treatment. All patients were screened by us and screening included a negative Q-Tip test, wet smears, vaginal cultures, and a negative clinical vulvar examination. An acupuncturist performed all the treatments. Dermatological lesions such as eczema, psoriasis, lichen simplex sclerosis and atrophicus, and planus were excluded. Cyclic yeast vaginitis, human papillomavirus, vulvar intraepithelial neoplasia, and localized dysesthesia (vestibulodynia) were also excluded. Patients did not receive antidepressive or antiepileptic medication at the acupuncture treatment or for 4 months thereafter.

Acupuncture is defined as an insertion of a needle on precise points of the body.9 The rationale is based on Traditional Chinese Medicine (TCM), covering Yin-Yang, Five Elements, Baguang, Meridians theories, and reflexology. According to the age of the patient and the duration of the problem, we referred to Liver (Shu Jueyin) and Bladder (Shu Taiyang) meridians (young persons, few months to a year of discomfort). Also, the Chong and Tae Mo (Curious Meridians) were considered. If symptoms were present for longer than a year, the diagnosis of Liver and Kidney Yin deficiency was considered, with apparent Fire or false Fire. In reference to the nervous system, neuralgia appeared stronger at the T2-T5 levels and lighter on L1-L5, including sacral holes painful pressure points. Literature sources are the confluence of French, Chinese, and American studies.9Stainless steel needles from 2-6 cm and 0.25 mm diameter (#32), and 6 cm and 0.25 mm diameter (#32) were used (Suzhou Shenlong Medical Apparatus Co Ltd, China). They were individually packed in an aluminum and plastic plate of thin needles, then sterilized and discarded after a single use.

Needles were placed according to the chosen locations and the person’s size, at a depth of 2-10 mm, perpendicularly or longitudinally, with different angles. Needles remained in place for 20-30 minutes in a comfortable position. We use needles without any manual or electric stimulation. Treatment was repeated weekly for 4 sessions. (Patients may indicate a pinch when skin is pierced. A feeling of numbness may be experienced near the site of puncture but it disappears with the removal of the needle, with some variations to the patient’s pain threshold.) Three main points were used for all patients: BL 22, SP 6, and LV 5, alternatively on the left and right meridians (Figure 1). No Qi response or T-witch response was used . Other interventions were: moxibustion below the navel segment level, according to the season, age, and general condition of the patient, and recommendation to avoid cold at all levels of food, clothing, and space. This study was undertaken in a private clinic setting.

A single-factor analysis of variance with repeated measures followed by a contrast analysis using paired t test with Bonferroni correction was used to study the pain level before the treatment, after 1 month, and after 4 months. The association between the ages of the patients, the duration of pain, and the pain level was studied with Pearson correlation.

RESULTSPatients’ mean (SD) age was 47.5 (15.3) years (range, 23-70 years) (Table 1). Mean symptom duration was 38.2 (18.6) months in 10 completed questionnaires. Mean pain score levels varied from 8.69 (1.75) in the pretreatment period to 4.38 (2.93) at 1 month to 2.31(2.66) at 4 months. These mean levels were significantly different (F=37.49, P<.001). Significant mean differences were observed between pretreatment and at 1 month (P<.001), and pretreatment and the end of the survey at 4 months (P<.001), and at 1 and 4 months (P=.02). One patient did not achieve any improvement, and another had a partial response (pain score reduced from 9 to 5). There were no treatment complications.

Table 1. Patient Information and Pain Outcomes

Pain on Visual Analog Scale (1-10)

Patient
No.

Age,
y

Duration,
mo

Before
Treatment

At
1 mo

At
4 mo

1

36

60

10

7

1

2

25

36

8

2

2

3

61

48

10

3

1

4

50

24

7

3

1

5

62

20

10

10

10

6

67

41

4

2

3

7

23

9

9

9

3

8

39

–

9

7

5

9

43

72

10

5

1

10

58

–

10

1

1

11

45

36

10

3

1

12

70

–

8

2

1

13

39

36

8

3

0

Mean

47.5

38.2

8.69

4.38

2.31

(SD)

(15.3)

(18.62)

(2.93)

(1.75)

(2.66)

Median
(range)

45
(23-70)

36
(9-72)

9

3

1

There wasn’t any significant linear relationship observed between age and duration (r=0.108, P=.77), age and pain levels at pretreatment (r=–0.230, P=.45), age and pain levels at 1 month (r=–0.327, P=.28) age and pain levels at 4 months (r=0.147, P=.63), duration and pain levels at pretreatment (r=0.195, P=.59), duration and pain levels at 1 month (r=–0.301, P=.40), and duration and pain levels at 4 months (r=-0.450, P=.19). The difference between the pain levels at 4 months and pretreatment was also not linearly related to age (r=0.259, P=.39) and duration (r=–0.502, P=.14).

Figure 1. BL 22 is located in the lumbar region and SP 6 and LV are on the antero-internal and mid-lower side of the leg

DISCUSSIONWe are unaware of any controlled trials of acupuncture treatment for vulvodynia.10 A controlled trial comparing acupuncture with amitriptyline would be challenging, especially with medium and long-term follow-up. Neuropathic pain mechanisms in vulvodynia remain unclear.11Recently, quantitative sensory testing showed increased vulvar pain presence and peripheral body regions12 with the evocation of a possible central control mechanism. Reed et al13emphasized minimal differences between general vulvar dysesthesia and vestibulodynia, with no significant differences between both groups. They could be the variant of the same pathophysiological mechanism.

Sexual activities appeared similar between vulvodynic patients and controls,14 although frequency of intercourse or orgasm was less frequent in the affected group. Our study could be extended to vestibulodynia without the aid of physiotherapy or sexual therapy. A longer period of evaluation of up to 12 months is deemed optimal with inclusion of amitriptyline as control. However, our study raises hopes in the short-term management of a challenging and often undetected syndrome.

CONCLUSIONSAcupuncture may be a possible alternative to antidepressant treatment for vulvodynia. A longer surveillance period is needed to verify our results.